As a result of a federal court decision, the Department of
Medical Assistance Services (DMAS) is changing the requirements for inpatient
psychiatric facilities (IPFs) and providers that offer certain services, such
as physician, medical, psychological, vision, dental, and emergency services,
to residents of IPFs. The affected IPFs are state freestanding psychiatric
hospitals, private freestanding psychiatric hospitals, and residential
treatment facilities (Level C). Item 307 CCC of Chapter 3 of the 2012 Acts of
Assembly, Special Session I, directs DMAS to develop changes to requirements
for nonfacility services furnished to individuals residing in IPFs to comply
with the court order and a prospective payment methodology to reimburse
institutions treating mental disease (residential treatment centers and
freestanding psychiatric hospitals) for services furnished by the facility and
by others.

Item 307 CCC of Chapter 806 of the 2013 Acts of Assembly
directs DMAS to require that institutions that treat mental diseases provide referral
services to their inpatients when an inpatient needs ancillary services. Item
301 XX of Chapter 3 of the 2014 Acts of Assembly, Special Session I, and Item
301 XX of Chapter 665 of the 2015 Acts of Assembly direct DMAS to revise
reimbursement for services furnished to Medicaid members in residential
treatment centers and freestanding psychiatric hospitals to include
professional, pharmacy, and other services to be reimbursed separately as long
as the services are in the plan of care developed by the residential treatment
center or the freestanding psychiatric hospital and arranged by the residential
treatment center or the freestanding psychiatric hospital.

The amendments conform the regulations to these
requirements.

Summary of Public Comments and Agency's Response: No
public comments were received by the promulgating agency.

12VAC30-50-130. Skilled nursingNursing facility
services, EPSDT, including school health services and family planning.

A. Skilled nursingNursing facility services
(other than services in an institution for mental diseases) for individuals 21
years of age or older.

Service must be ordered or prescribed and directed or
performed within the scope of a license of the practitioner of the healing
arts.

B. Early and periodic screening and diagnosis of individuals
under 21 years of age, and treatment of conditions found.

1. Payment of medical assistance services shall be made on
behalf of individuals under 21 years of age, who are Medicaid eligible, for
medically necessary stays in acute care facilities, and the accompanying
attendant physician care, in excess of 21 days per admission when such services
are rendered for the purpose of diagnosis and treatment of health conditions
identified through a physical examination.

2. Routine physicals and immunizations (except as provided
through EPSDT) are not covered except that well-child examinations in a private
physician's office are covered for foster children of the local social services
departments on specific referral from those departments.

3. Orthoptics services shall only be reimbursed if medically
necessary to correct a visual defect identified by an EPSDT examination or
evaluation. The department shall place appropriate utilization controls upon
this service.

4. Consistent with the Omnibus Budget Reconciliation Act of
1989 § 6403, early and periodic screening, diagnostic, and treatment services
means the following services: screening services, vision services, dental
services, hearing services, and such other necessary health care, diagnostic
services, treatment, and other measures described in Social Security Act §
1905(a) to correct or ameliorate defects and physical and mental illnesses and
conditions discovered by the screening services and which are medically
necessary, whether or not such services are covered under the State Plan and
notwithstanding the limitations, applicable to recipients ages 21 and over,
provided for by the Act § 1905(a) of the Social Security Act.

5. Community mental health services. These services in order
to be covered (i) shall meet medical necessity criteria based upon diagnoses
made by LMHPs who are practicing within the scope of their licenses and (ii)
are reflected in provider records and on providers' claims for services by
recognized diagnosis codes that support and are consistent with the requested
professional services.

a. Definitions. The following words and terms when used in
this section shall have the following meanings unless the context clearly
indicates otherwise:

"Adolescent or child" means the individual receiving
the services described in this section. For the purpose of the use of these
terms, adolescent means an individual 12-20 years of age; a child means an
individual from birth up to 12 years of age.

"Behavioral health services administrator" or
"BHSA" means an entity that manages or directs a behavioral health
benefits program under contract with DMAS.

"Care coordination" means collaboration and sharing
of information among health care providers, who are involved with an
individual's health care, to improve the care.

"Certified prescreener" means an employee of the
local community services board or behavioral health authority, or its designee,
who is skilled in the assessment and treatment of mental illness and has
completed a certification program approved by the Department of Behavioral
Health and Developmental Services.

"Clinical experience" means providing direct
behavioral health services on a full-time basis or equivalent hours of
part-time work to children and adolescents who have diagnoses of mental illness
and includes supervised internships, supervised practicums, and supervised
field experience for the purpose of Medicaid reimbursement of (i) intensive
in-home services, (ii) day treatment for children and adolescents, (iii)
community-based residential services for children and adolescents who are
younger than 21 years of age (Level A), or (iv) therapeutic behavioral services
(Level B). Experience shall not include unsupervised internships, unsupervised
practicums, and unsupervised field experience. The equivalency of part-time
hours to full-time hours for the purpose of this requirement shall be as
established by DBHDS in the document entitled Human Services and Related Fields
Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.

"DBHDS" means the Department of Behavioral Health
and Developmental Services.

"DMAS" means the Department of Medical Assistance
Services and its contractor or contractors.

"EPSDT" means early and periodic screening,
diagnosis, and treatment.

"Human services field" means the same as the term is
defined by DBHDS in the document entitled Human Services and Related Fields
Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.

"Individual service plan" or "ISP" means
the same as the term is defined in 12VAC30-50-226.

"LMHP-resident" or "LMHP-R" means the same
as "resident" as defined in (i) 18VAC115-20-10 for licensed
professional counselors; (ii) 18VAC115-50-10 for licensed marriage and family
therapists; or (iii) 18VAC115-60-10 for licensed substance abuse treatment
practitioners. An LMHP-resident shall be in continuous compliance with the
regulatory requirements of the applicable counseling profession for supervised
practice and shall not perform the functions of the LMHP-R or be considered a
"resident" until the supervision for specific clinical duties at a
specific site has been preapproved in writing by the Virginia Board of
Counseling. For purposes of Medicaid reimbursement to their supervisors for
services provided by such residents, they shall use the title "Resident"
in connection with the applicable profession after their signatures to indicate
such status.

"LMHP-resident in psychology" or "LMHP-RP"
means the same as an individual in a residency, as that term is defined in
18VAC125-20-10, program for clinical psychologists. An LMHP-resident in
psychology shall be in continuous compliance with the regulatory requirements
for supervised experience as found in 18VAC125-20-65 and shall not perform the
functions of the LMHP-RP or be considered a "resident" until the
supervision for specific clinical duties at a specific site has been
preapproved in writing by the Virginia Board of Psychology. For purposes of
Medicaid reimbursement by supervisors for services provided by such residents,
they shall use the title "Resident in Psychology" after their
signatures to indicate such status.

"LMHP-supervisee in social work,"
"LMHP-supervisee," or "LMHP-S" means the same as
"supervisee" as defined in 18VAC140-20-10 for licensed clinical
social workers. An LMHP-supervisee in social work shall be in continuous
compliance with the regulatory requirements for supervised practice as found in
18VAC140-20-50 and shall not perform the functions of the LMHP-S or be
considered a "supervisee" until the supervision for specific clinical
duties at a specific site is preapproved in writing by the Virginia Board of
Social Work. For purposes of Medicaid reimbursement to their supervisors for
services provided by supervisees, these persons shall use the title
"Supervisee in Social Work" after their signatures to indicate such
status.

"Progress notes" means individual-specific
documentation that contains the unique differences particular to the
individual's circumstances, treatment, and progress that is also signed and
contemporaneously dated by the provider's professional staff who have prepared
the notes. Individualized and member-specific progress notes are part of the
minimum documentation requirements and shall convey the individual's status,
staff interventions, and, as appropriate, the individual's progress, or lack of
progress, toward goals and objectives in the ISP. The progress notes shall also
include, at a minimum, the name of the service rendered, the date of the
service rendered, the signature and credentials of the person who rendered the
service, the setting in which the service was rendered, and the amount of time
or units/hours required to deliver the service. The content of each progress
note shall corroborate the time/units billed. Progress notes shall be
documented for each service that is billed.

"Psychoeducation" means (i) a specific form of
education aimed at helping individuals who have mental illness and their family
members or caregivers to access clear and concise information about mental
illness and (ii) a way of accessing and learning strategies to deal with mental
illness and its effects in order to design effective treatment plans and
strategies.

"Psychoeducational activities" means systematic
interventions based on supportive and cognitive behavior therapy that
emphasizes an individual's and his family's needs and focuses on increasing the
individual's and family's knowledge about mental disorders, adjusting to mental
illness, communicating and facilitating problem solving and increasing coping
skills.

"Qualified mental health professional-child" or
"QMHP-C" means the same as the term is defined in 12VAC35-105-20.

"Qualified mental health professional-eligible" or
"QMHP-E" means the same as the term is defined in 12VAC35-105-20 and
consistent with the requirements of 12VAC35-105-590.

"Qualified paraprofessional in mental health" or
"QPPMH" means the same as the term is defined in
12VAC35-105-20 and consistent with the requirements of 12VAC35-105-1370.

"Service-specific provider intake" means the
face-to-face interaction in which the provider obtains information from the
child or adolescent, and parent or other family member or members, as
appropriate, about the child's or adolescent's mental health status. It
includes documented history of the severity, intensity, and duration of mental
health care problems and issues and shall contain all of the following
elements: (i) the presenting issue/reason for referral, (ii) mental health
history/hospitalizations, (iii) previous interventions by providers and
timeframes and response to treatment, (iv) medical profile, (v) developmental
history including history of abuse, if appropriate, (vi) educational/vocational
status, (vii) current living situation and family history and relationships,
(viii) legal status, (ix) drug and alcohol profile, (x) resources and
strengths, (xi) mental status exam and profile, (xii) diagnosis, (xiii)
professional summary and clinical formulation, (xiv) recommended care and
treatment goals, and (xv) the dated signature of the LMHP, LMHP-supervisee,
LMHP-resident, or LMHP-RP.

"Services provided under arrangement" means the
same as defined in 12VAC30-130-850.

b. Intensive in-home services (IIH) to children and
adolescents under age 21 shall be time-limited interventions provided in the
individual's residence and when clinically necessary in community settings. All
interventions and the settings of the intervention shall be defined in the
Individual Service Plan. All IIH services shall be designed to specifically
improve family dynamics, provide modeling, and the clinically necessary
interventions that increase functional and therapeutic interpersonal relations
between family members in the home. IIH services are designed to promote
psychoeducational benefits in the home setting of an individual who is at risk
of being moved into an out-of-home placement or who is being transitioned to
home from an out-of-home placement due to a documented medical need of the
individual. These services provide crisis treatment; individual and family
counseling; communication skills (e.g., counseling to assist the individual and
his parents or guardians, as appropriate, to understand and practice
appropriate problem solving, anger management, and interpersonal interaction,
etc.); care coordination with other required services; and 24-hour emergency
response.

(1) These services shall be limited annually to 26 weeks.
Service authorization shall be required for Medicaid reimbursement prior to the
onset of services. Services rendered before the date of authorization shall not
be reimbursed.

(2) Service authorization shall be required for services to
continue beyond the initial 26 weeks.

(3) Service-specific provider intakes shall be required at the
onset of services and ISPs shall be required during the entire duration of
services. Services based upon incomplete, missing, or outdated service-specific
provider intakes or ISPs shall be denied reimbursement. Requirements for
service-specific provider intakes and ISPs are set out in this section.

(4) These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or a QMHP-E.

c. Therapeutic day treatment (TDT) shall be provided two or
more hours per day in order to provide therapeutic interventions. Day treatment
programs, limited annually to 780 units, provide evaluation; medication
education and management; opportunities to learn and use daily living skills
and to enhance social and interpersonal skills (e.g., problem solving, anger management,
community responsibility, increased impulse control, and appropriate peer
relations, etc.); and individual, group and family counseling.

(1) Service authorization shall be required for Medicaid
reimbursement.

(2) Service-specific provider intakes shall be required at the
onset of services and ISPs shall be required during the entire duration of
services. Services based upon incomplete, missing, or outdated service-specific
provider intakes or ISPs shall be denied reimbursement. Requirements for service-specific
provider intakes and ISPs are set out in this section.

(3) These services may be rendered only by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or a QMHP-E.

d. Community-based services for children and adolescents under
21 years of age (Level A) pursuant to 42 CFR 440.130(d).

(1) Such services shall be a combination of therapeutic
services rendered in a residential setting. The residential services will
provide structure for daily activities, psychoeducation, therapeutic supervision,
care coordination, and psychiatric treatment to ensure the attainment of
therapeutic mental health goals as identified in the individual service plan
(plan of care). Individuals qualifying for this service must demonstrate
medical necessity for the service arising from a condition due to mental,
behavioral or emotional illness that results in significant functional
impairments in major life activities in the home, school, at work, or in the
community. The service must reasonably be expected to improve the child's
condition or prevent regression so that the services will no longer be needed.
The application of a national standardized set of medical necessity criteria in
use in the industry, such as McKesson InterQual® Criteria or an
equivalent standard authorized in advance by DMAS, shall be required for this
service.

(2) In addition to the residential services, the child must
receive, at least weekly, individual psychotherapy that is provided by an LMHP,
LMHP-supervisee, LMHP-resident, or LMHP-RP.

(3) Individuals shall be discharged from this service when
other less intensive services may achieve stabilization.

(4) Authorization shall be required for Medicaid
reimbursement. Services that were rendered before the date of service
authorization shall not be reimbursed.

(5) Room and board costs shall not be reimbursed. DMAS shall
reimburse only for services provided in facilities or programs with no more
than 16 beds.

(6) These residential providers must be licensed by the
Department of Social Services, Department of Juvenile Justice, or Department of
Behavioral Health and Developmental Services under the Standards for Licensed
Children's Residential Facilities (22VAC40-151), Standards for Interim
Regulation of Children's Residential Facilities (6VAC35-51)Regulation
Governing Juvenile Group Homes and Halfway Houses (6VAC35-41), or
Regulations for Children's Residential Facilities (12VAC35-46).

(7) Daily progress notes shall document a minimum of seven
psychoeducational activities per week. Psychoeducational programming must
include, but is not limited to, development or maintenance of daily living
skills, anger management, social skills, family living skills, communication
skills, stress management, and any care coordination activities.

(8) The facility/group home must coordinate services with
other providers. Such care coordination shall be documented in the individual's
medical record. The documentation shall include who was contacted, when the
contact occurred, and what information was transmitted.

(9) Service-specific provider intakes shall be required at the
onset of services and ISPs shall be required during the entire duration of
services. Services based upon incomplete, missing, or outdated service-specific
provider intakes or ISPs shall be denied reimbursement. Requirements for
intakes and ISPs are set out in 12VAC30-60-61.

(10) These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH.

(1) Such services must be therapeutic services rendered in a
residential setting that providesprovide structure for daily
activities, psychoeducation, therapeutic supervision, care coordination, and
psychiatric treatment to ensure the attainment of therapeutic mental health
goals as identified in the individual service plan (plan of care). Individuals
qualifying for this service must demonstrate medical necessity for the service
arising from a condition due to mental, behavioral or emotional illness that
results in significant functional impairments in major life activities in the
home, school, at work, or in the community. The service must reasonably be
expected to improve the child's condition or prevent regression so that the
services will no longer be needed. The application of a national standardized
set of medical necessity criteria in use in the industry, such as McKesson
InterQual® Criteria, or an equivalent standard authorized in advance
by DMAS shall be required for this service.

(2) Authorization is required for Medicaid reimbursement.
Services that are rendered before the date of service authorization shall not
be reimbursed.

(3) Room and board costs shall not be reimbursed. Facilities
that only provide independent living services are not reimbursed. DMAS shall
reimburse only for services provided in facilities or programs with no more
than 16 beds.

(4) These residential providers must be licensed by the
Department of Behavioral Health and Developmental Services (DBHDS) under the
Regulations for Children's Residential Facilities (12VAC35-46).

(5) Daily progress notes shall document that a minimum of
seven psychoeducational activities per week occurs. Psychoeducational
programming must include, but is not limited to, development or maintenance of
daily living skills, anger management, social skills, family living skills,
communication skills, and stress management. This service may be provided in a
program setting or a community-based group home.

(6) The individual must receive, at least weekly, individual
psychotherapy and, at least weekly, group psychotherapy that is provided as
part of the program.

(7) Individuals shall be discharged from this service when
other less intensive services may achieve stabilization.

(8) Service-specific provider intakes shall be required at the
onset of services and ISPs shall be required during the entire duration of
services. Services that are based upon incomplete, missing, or outdated
service-specific provider intakes or ISPs shall be denied reimbursement.
Requirements for intakes and ISPs are set out in 12VAC30-60-61.

(9) These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH.

(10) The facility/group home shall coordinate necessary
services with other providers. Documentation of this care coordination shall be
maintained by the facility/group home in the individual's record. The
documentation shall include who was contacted, when the contact occurred, and
what information was transmitted.

6. Inpatient psychiatric services shall be covered for
individuals younger than age 21 for medically necessary stays in inpatient
psychiatric facilities described in 42 CFR 440.160(b)(1) and (b)(2)
for the purpose of diagnosis and treatment of mental health and behavioral
disorders identified under EPSDT when such services are rendered by: a. A(i) a psychiatric hospital or an inpatient psychiatric program in a
hospital accredited by the Joint Commission on Accreditation of Healthcare
Organizations; or (ii) a psychiatric facility that is accredited
by the Joint Commission on Accreditation of Healthcare Organizations,or
the Commission on Accreditation of Rehabilitation Facilities, the Council on
Accreditation of Services for Families and Children or the Council on Quality
and Leadership. b. Inpatient psychiatric hospital admissions at
general acute care hospitals and freestanding psychiatric hospitals shall also
be subject to the requirements of 12VAC30-50-100, 12VAC30-50-105, and 12VAC30-60-25.
Inpatient psychiatric admissions to residential treatment facilities shall also
be subject to the requirements of Part XIV (12VAC30-130-850 et seq.) of Amount,
Duration and Scope of Selected Services12VAC30-130.

a. The inpatient psychiatric services benefit for
individuals younger than 21 years of age shall include services defined at 42
CFR 440.160 that are provided under the direction of a physician pursuant to a
certification of medical necessity and plan of care developed by an
interdisciplinary team of professionals and shall involve active treatment
designed to achieve the child's discharge from inpatient status at the earliest
possible time. The inpatient psychiatric services benefit shall include
services provided under arrangement furnished by Medicaid enrolled providers
other than the inpatient psychiatric facility, as long as the inpatient
psychiatric facility (i) arranges for and oversees the provision of all
services, (ii) maintains all medical records of care furnished to the
individual, and (iii) ensures that the services are furnished under the
direction of a physician. Services provided under arrangement shall be
documented by a written referral from the inpatient psychiatric facility. For
purposes of pharmacy services, a prescription ordered by an employee or
contractor of the facility who is licensed to prescribe drugs shall be
considered the referral.

b. Eligible services provided under arrangement with the
inpatient psychiatric facility shall vary by provider type as described in this
subsection. For purposes of this section, emergency services means the same as
is set out in 12VAC30-50-310 B.

c. Inpatient psychiatric services are reimbursable only when
the treatment program is fully in compliance with (i) 42 CFR
Part 441 Subpart D, as contained inspecifically 42 CFR
441.151(a) and (b) and 441.152 through 441.156, and (ii) the conditions of
participation in 42 CFR Part 483 Subpart G. Each admission must be
preauthorized and the treatment must meet DMAS requirements for clinical
necessity.

d. Service limits may be exceeded based on medical
necessity for individuals eligible for EPSDT.

7. Hearing aids shall be reimbursed for individuals younger
than 21 years of age according to medical necessity when provided by
practitioners licensed to engage in the practice of fitting or dealing in
hearing aids under the Code of Virginia.

2. School divisions may provide routine well-child screening
services under the State Plan. Diagnostic and treatment services that are
otherwise covered under early and periodic screening, diagnosis and treatment
services, shall not be covered for school divisions. School divisions to
receive reimbursement for the screenings shall be enrolled with DMAS as clinic
providers.

a. Children enrolled in managed care organizations shall
receive screenings from those organizations. School divisions shall not receive
reimbursement for screenings from DMAS for these children.

b. School-based services are listed in a recipient's
individualized education program (IEP) and covered under one or more of the
service categories described in § 1905(a) of the Social Security Act. These
services are necessary to correct or ameliorate defects of physical or mental
illnesses or conditions.

3. Service providers shall be licensed under the applicable
state practice act or comparable licensing criteria by the Virginia Department
of Education, and shall meet applicable qualifications under 42 CFR
Part 440. Identification of defects, illnesses or conditions and services
necessary to correct or ameliorate them shall be performed by practitioners
qualified to make those determinations within their licensed scope of practice,
either as a member of the IEP team or by a qualified practitioner outside the
IEP team.

a. Service providers shall be employed by the school division
or under contract to the school division.

b. Supervision of services by providers recognized in
subdivision 4 of this subsection shall occur as allowed under federal
regulations and consistent with Virginia law, regulations, and DMAS provider
manuals.

c. The services described in subdivision 4 of this subsection
shall be delivered by school providers, but may also be available in the
community from other providers.

d. Services in this subsection are subject to utilization
control as provided under 42 CFR Parts 455 and 456.

e. The IEP shall determine whether or not the services
described in subdivision 4 of this subsection are medically necessary and that
the treatment prescribed is in accordance with standards of medical practice.
Medical necessity is defined as services ordered by IEP providers. The IEP
providers are qualified Medicaid providers to make the medical necessity
determination in accordance with their scope of practice. The services must be
described as to the amount, duration and scope.

4. Covered services include:

a. Physical therapy, occupational therapy and services for
individuals with speech, hearing, and language disorders, performed by, or
under the direction of, providers who meet the qualifications set forth at 42
CFR 440.110. This coverage includes audiology services;

b. Skilled nursing services are covered under 42 CFR
440.60. These services are to be rendered in accordance to the licensing
standards and criteria of the Virginia Board of Nursing. Nursing services are
to be provided by licensed registered nurses or licensed practical nurses but
may be delegated by licensed registered nurses in accordance with the regulations
of the Virginia Board of Nursing, especially the section on delegation of
nursing tasks and procedures. The licensed practical nurse is under the
supervision of a registered nurse.

(1) The coverage of skilled nursing services shall be of a
level of complexity and sophistication (based on assessment, planning,
implementation and evaluation) that is consistent with skilled nursing services
when performed by a licensed registered nurse or a licensed practical nurse.
These skilled nursing services shall include, but not necessarily be limited to
dressing changes, maintaining patent airways, medication
administration/monitoring and urinary catheterizations.

(2) Skilled nursing services shall be directly and
specifically related to an active, written plan of care developed by a
registered nurse that is based on a written order from a physician, physician
assistant or nurse practitioner for skilled nursing services. This order shall
be recertified on an annual basis.

c. Psychiatric and psychological services performed by
licensed practitioners within the scope of practice are defined under state law
or regulations and covered as physicians' services under 42 CFR 440.50 or
medical or other remedial care under 42 CFR 440.60. These outpatient
services include individual medical psychotherapy, group medical psychotherapy
coverage, and family medical psychotherapy. Psychological and
neuropsychological testing are allowed when done for purposes other than
educational diagnosis, school admission, evaluation of an individual with
intellectual disability prior to admission to a nursing facility, or any
placement issue. These services are covered in the nonschool settings also.
School providers who may render these services when licensed by the state
include psychiatrists, licensed clinical psychologists, school psychologists,
licensed clinical social workers, professional counselors, psychiatric clinical
nurse specialist, marriage and family therapists, and school social workers.

d. Personal care services are covered under 42 CFR
440.167 and performed by persons qualified under this subsection. The personal
care assistant is supervised by a DMAS recognized school-based health
professional who is acting within the scope of licensure. This practitioner
develops a written plan for meeting the needs of the child, which is
implemented by the assistant. The assistant must have qualifications comparable
to those for other personal care aides recognized by the Virginia Department of
Medical Assistance Services. The assistant performs services such as assisting
with toileting, ambulation, and eating. The assistant may serve as an aide on a
specially adapted school vehicle that enables transportation to or from the
school or school contracted provider on days when the student is receiving a
Medicaid-covered service under the IEP. Children requiring an aide during
transportation on a specially adapted vehicle shall have this stated in the
IEP.

e. Medical evaluation services are covered as physicians'
services under 42 CFR 440.50 or as medical or other remedial care under 42 CFR
440.60. Persons performing these services shall be licensed physicians,
physician assistants, or nurse practitioners. These practitioners shall
identify the nature or extent of a child's medical or other health related
condition.

f. Transportation is covered as allowed under 42 CFR
431.53 and described at State Plan Attachment 3.1-D (12VAC30-50-530).
Transportation shall be rendered only by school division personnel or
contractors. Transportation is covered for a child who requires transportation
on a specially adapted school vehicle that enables transportation to or from
the school or school contracted provider on days when the student is receiving
a Medicaid-covered service under the IEP. Transportation shall be listed in the
child's IEP. Children requiring an aide during transportation on a specially
adapted vehicle shall have this stated in the IEP.

g. Assessments are covered as necessary to assess or reassess
the need for medical services in a child's IEP and shall be performed by any of
the above licensed practitioners within the scope of practice. Assessments and
reassessments not tied to medical needs of the child shall not be covered.

5. DMAS will ensure through quality management review that
duplication of services will be monitored. School divisions have a
responsibility to ensure that if a child is receiving additional therapy
outside of the school, that there will be coordination of services to avoid
duplication of service.

D. Family planning services and supplies for individuals of
child-bearing age.

1. Service must be ordered or prescribed and directed or
performed within the scope of the license of a practitioner of the healing
arts.

2. Family planning services shall be defined as those services
that delay or prevent pregnancy. Coverage of such services shall not include
services to treat infertility nor services to promote fertility.

A. Psychiatric services in freestanding psychiatric hospitals
shall only be covered for eligible persons younger than 21 years of age and
older than 64 years of age.

B. Prior authorization required. DMAS shall monitor,
consistent with state law, the utilization of all inpatient freestanding
psychiatric hospital services. All inpatient hospital stays shall be
preauthorized prior to reimbursement for these services. Services rendered
without such prior authorization shall not be covered.

C. All Medicaid services are subject to utilization review
and audit. Absence of any of the required documentation may result in denial or
retraction of any reimbursement. In each case for which payment for
freestanding psychiatric hospital services is made under the State Plan:

1. A physician must certify at the time of admission, or at
the time the hospital is notified of an individual's retroactive eligibility
status, that the individual requires or required inpatient services in a
freestanding psychiatric hospital consistent with 42 CFR 456.160.

2. The physician, physician assistant, or nurse practitioner
acting within the scope of practice as defined by state law and under the
supervision of a physician, must recertify at least every 60 days that the
individual continues to require inpatient services in a psychiatric hospital.

3. Before admission to a freestanding psychiatric hospital or
before authorization for payment, the attending physician or staff physician must
perform a medical evaluation of the individual and appropriate professional
personnel must make a psychiatric and social evaluation as cited in 42 CFR
456.170.

4. Before admission to a freestanding psychiatric hospital or
before authorization for payment, the attending physician or staff physician
must establish a written plan of care for each recipient patient as cited in 42
CFR 441.155 and 456.180. The plan shall also include a list of services
provided under written contractual arrangement with the freestanding
psychiatric hospital (see 12VAC30-50-130) that will be furnished to the patient
through the freestanding psychiatric hospital's referral to an employed or
contracted provider, including the prescribed frequency of treatment and the
circumstances under which such treatment shall be sought.

D. If the eligible individual is 21 years of age or older,
then, in order to qualify for Medicaid payment for this service, he must be at
least 65 years of age.

E. If younger than 21 years of age, it shall be documented
that the individual requiring admission to a freestanding psychiatric hospital
is under 21 years of age, that treatment is medically necessary, and that the
necessity was identified as a result of an early and periodic screening,
diagnosis, and treatment (EPSDT) screening. Required patient documentation
shall include, but not be limited to, the following:

1. An EPSDT physician's screening report showing the
identification of the need for further psychiatric evaluation and possible
treatment.

2. A diagnostic evaluation documenting a current (active)
psychiatric disorder included in the DSM-III-R that supports the treatment
recommended. The diagnostic evaluation must be completed prior to admission.

3. For admission to a freestanding psychiatric hospital for
psychiatric services resulting from an EPSDT screening, a certification of the
need for services as defined in 42 CFR 441.152 by an interdisciplinary
team meeting the requirements of 42 CFR 441.153 or 441.156 and theThe
Psychiatric Inpatient Treatment of Minors Act (§ 16.1-335 et seq. of the
Code of Virginia).

F. If a Medicaid eligible individual is admitted in an
emergency to a freestanding psychiatric hospital on a Saturday, Sunday,
holiday, or after normal working hours, it shall be the provider's
responsibility to obtain the required authorization on the next work day
following such an admission.

G. The absence of any of the required documentation
described in this subsection shall result in DMAS' denial of the requested
preauthorization and coverage of subsequent hospitalization.

F.H. To determine that the DMAS enrolled
mental hospital providers are in compliance with the regulations governing
mental hospital utilization control found in the 42 CFR 456.150, an annual
audit will be conducted of each enrolled hospital. This audit may be performed
either on site or as a desk audit. The hospital shall make all requested
records available and shall provide an appropriate place for the auditors to
conduct such review if done on site. The audits shall consist of review of the
following:

1. Copy of the mental hospital's Utilization Management Plan
to determine compliance with the regulations found in the 42 CFR 456.200
through 456.245.

2. List of current Utilization Management Committee members
and physician advisors to determine that the committee's composition is as
prescribed in the 42 CFR 456.205 and 456.206.

3. Verification of Utilization Management Committee meetings,
including dates and list of attendees to determine that the committee is
meeting according to their utilization management meeting requirements.

4. One completed Medical Care Evaluation Study to include
objectives of the study, analysis of the results, and actions taken, or
recommendations made to determine compliance with 42 CFR 456.241 through
456.245.

5. Topic of one ongoing Medical Care Evaluation Study to
determine the hospital is in compliance with 42 CFR 456.245.

6. From a list of randomly selected paid claims, the
freestanding psychiatric hospital must provide a copy of the certification for
services, a copy of the physician admission certification, a copy of the
required medical, psychiatric, and social evaluations, and the written plan of
care for each selected stay to determine the hospital's compliance with §§ 16.1-335
through 16.1-348 of the Code of Virginia and 42 CFR 441.152, 456.160,
456.170, 456.180 and 456.181. If any of the required documentation does not
support the admission and continued stay, reimbursement may be retracted.

I. The freestanding psychiatric hospital shall not receive
a per diem reimbursement for any day that:

1. The initial or comprehensive written plan of care fails
to include within three business days of the initiation of the service provided
under arrangement all services that the individual needs while at the
freestanding psychiatric hospital and that will be furnished to the individual
through the freestanding psychiatric hospital's referral to an employed or
contracted provider of services under arrangement;

2. The comprehensive plan of care fails to include within
three business days of the initiation of the service the prescribed frequency
of such service or includes a frequency that was exceeded;

3. The comprehensive plan of care fails to list the
circumstances under which the service provided under arrangement shall be
sought;

4. The referral to the service provided under arrangement
was not present in the patient's freestanding psychiatric hospital record;

5. The service provided under arrangement was not supported
in that provider's records by a documented referral from the freestanding
psychiatric hospital;

6. The medical records from the provider of services under
arrangement (i.e., admission and discharge documents, treatment plans, progress
notes, treatment summaries, and documentation of medical results and findings)
(i) were not present in the patient's freestanding psychiatric hospital record
or had not been requested in writing by the freestanding psychiatric hospital
within seven days of completion of the service or services provided under
arrangement or (ii) had been requested in writing within seven days of
completion of the service or services, but had not been received within 30 days
of the request, and had not been re-requested;

7. The freestanding psychiatric hospital did not have a
fully executed contract or an employee relationship with the provider of
services under arrangement in advance of the provision of such services. For
emergency services, the freestanding psychiatric hospital shall have a fully
executed contract with the emergency services hospital provider prior to
submission of the ancillary provider's claim for payment.

J. The provider of services under arrangement shall be
required to reimburse DMAS for the cost of any such service billed prior to receiving
a referral from the freestanding psychiatric hospital or in excess of the
amounts in the referral.

K. The hospitals may appeal in accordance with the
Administrative Process Act (§ 9-6.14:12.2-4000 et seq. of the
Code of Virginia) any adverse decision resulting from such audits whichthat
results in retraction of payment. The appeal must be requested within 30
days of the date of the letter notifying the hospital of the retractionpursuant
to the requirements of 12VAC30-20-500 et seq.

A. The state agency will pay for inpatient hospital services
in general acute care hospitals, rehabilitation hospitals, and freestanding
psychiatric facilities licensed as hospitals under a prospective payment
methodology. This methodology uses both per case and per diem payment methods.
Article 2 (12VAC30-70-221 et seq.) of this part describes the
prospective payment methodology, including both the per case and the per diem
methods.

B. Article 3 (12VAC30-70-400 et seq.) of this part
describes a per diem methodology that applied to a portion of payment to
general acute care hospitals during state fiscal years 1997 and 1998,
and that will continue to apply to patient stays with admission dates prior to
July 1, 1996. Inpatient hospital services that are provided in long stay
hospitals shall be subject to the provisions of Supplement 3 (12VAC30-70-10
through 12VAC30-70-130).

C. Inpatient hospital facilities operated by the Department
of Behavioral Health and Developmental Services (DBHDS) shall be reimbursed
costs except for inpatient psychiatric services furnished under early and
periodic screening, diagnosis, and treatment (EPSDT) services for individuals
younger than age 21. These inpatient services shall be reimbursed according to
12VAC30-70-415 and shall be provided according to the requirements set forth in
12VAC30-50-130 and 12VAC30-60-25 H. Facilities may also receive
disproportionate share hospital (DSH) payments. The criteria for DSH
eligibility and the payment amount shall be based on subsection F of
12VAC30-70-50. If the DSH limit is exceeded by any facility, the excess DSH
payments shall be distributed to all other qualifying DBHDS facilities in
proportion to the amount of DSH they otherwise receive.

D. Transplant services shall not be subject to the provisions
of this part. Reimbursement for covered liver, heart, and bone marrow/stem cell
transplant services and any other medically necessary transplantation
procedures that are determined to not be experimental or investigational shall
be a fee based upon the greater of a prospectively determined,
procedure-specific flat fee determined by the agency or a prospectively
determined, procedure-specific percentage of usual and customary charges. The
flat fee reimbursement will cover procurement costs; all hospital costs from
admission to discharge for the transplant procedure; and total physician costs
for all physicians providing services during the hospital stay, including
radiologists, pathologists, oncologists, surgeons, etc. The flat fee
reimbursement does not include pre-hospitalization and
post-hospitalization for the transplant procedure or pretransplant evaluation.
If the actual charges are lower than the fee, the agency shall reimburse the
actual charges. Reimbursement for approved transplant procedures that are
performed out of state will be made in the same manner as reimbursement for
transplant procedures performed in the Commonwealth. Reimbursement for covered
kidney and cornea transplants is at the allowed Medicaid rate. Standards for
coverage of organ transplant services are in 12VAC30-50-540 through 12VAC30-50-580.

E. Reduction of payments methodology.

1. For state fiscal years 2003 and 2004, the Department of
Medical Assistance Services (DMAS) shall reduce payments to hospitals
participating in the Virginia Medicaid Program by $8,935,825 total funds, and
$9,227,815 total funds respectively. For purposes of distribution, each
hospital's share of the total reduction amount shall be determined as provided
in this subsection.

2. Determine base for revenue forecast.

a. DMAS shall use, as a base for determining the payment
reduction distribution for hospitals Type I and Type II, net Medicaid inpatient
operating reimbursement and outpatient reimbursed cost, as recorded by DMAS for
state fiscal year 1999 from each individual hospital settled cost reports. This
figure is further reduced by 18.73%, which represents the estimated statewide
HMO average percentage of Medicaid business for those hospitals engaged in HMO
contracts, to arrive at net baseline proportion of non-HMO hospital Medicaid
business.

b. For freestanding psychiatric hospitals, DMAS shall use
estimated Medicaid revenues for the six-month period (January 1, 2001, through
June 30, 2001), times two, and adjusted for inflation by 4.3% for state fiscal
year 2002, 3.1% for state fiscal year 2003, and 3.7% for state fiscal year
2004, as reported by DRI-WEFA, Inc.'s, hospital input price level percentage
moving average.

3. Determine forecast revenue.

a. Each Type I hospital's individual state fiscal year 2003
and 2004 forecast reimbursement is based on the proportion of non-HMO business
(see subdivision 2 a of this subsection) with respect to the DMAS forecast of
SFY 2003 and 2004 inpatient and outpatient operating revenue for Type I
hospitals.

b. Each Type II, including freestanding psychiatric,
hospital's individual state fiscal year 2003 and 2004 forecast reimbursement is
based on the proportion of non-HMO business (see subdivision 2 of this subsection)
with respect to the DMAS forecast of SFY 2003 and 2004 inpatient and outpatient
operating revenue for Type II hospitals.

4. Each hospital's total yearly reduction amount is equal to theirits respective state fiscal year 2003 and 2004 forecast reimbursement as
described in subdivision 3 of this subsection, times 3.235857% for state fiscal
year 2003, and 3.235857%, for the first two quarters of state fiscal year 2004
and 2.88572% for the last two quarters of state fiscal year 2004, not to be
reduced by more than $500,000 per year.

5. Reductions shall occur quarterly in four amounts as offsets
to remittances. Each hospital's payment reduction shall not exceed that
calculated in subdivision 4 of this subsection. Payment reduction offsets not
covered by claims remittance by May 15, 2003, and 2004, will be billed by
invoice to each provider with the remaining balances payable by check to the
Department of Medical Assistance Services before June 30, 2003, or 2004, as
applicable.

1. Health care-acquired conditions (HCACs). HCACs are
conditions occurring in any hospital setting, identified as a hospital-acquired
condition (HAC) by Medicare other than deep vein thrombosis (DVT)/pulmonary
embolism (PE) following total knee replacement or hip replacement surgery in
pediatric and obstetric patients.

2. Other provider preventable conditions (OPPCs) as follows:
(i) wrong surgical or other invasive procedure performed on a patient; (ii)
surgical or other invasive procedure performed on the wrong body part; or (iii)
surgical or other invasive procedure performed on the wrong patient.

12VAC30-70-321. Hospital specific operating rate per day.

A. The hospital specific operating rate per day shall be
equal to the labor portion of the statewide operating rate per day, as
determined in subsection A of 12VAC30-70-341, times the hospital's Medicare
wage index plus the nonlabor portion of the statewide operating rate per day.

B. For rural hospitals, the hospital's Medicare wage index
used in this section shall be the Medicare wage index of the nearest
metropolitan wage area or the effective Medicare wage index, whichever is
higher.

C. Effective July 1, 2008, and ending after June 30, 2010,
the hospital specific operating rate per day shall be reduced by 2.683%.

D. The hospital specific rate per day for freestanding
psychiatric cases shall be equal to the hospital specific operating rate per
day, as determined in subsection A of this section plus the hospital specific
capital rate per day for freestanding psychiatric cases.

E. The hospital specific capital rate per day for
freestanding psychiatric cases shall be equal to the Medicare geographic
adjustment factor for the hospital's geographic area, times the statewide
capital rate per day for freestanding psychiatric cases times the percentage of
allowable cost specified in 12VAC30-70-271.

F. The statewide capital rate per day for freestanding
psychiatric cases shall be equal to the weighted average of the
GAF-standardized capital cost per day of freestanding psychiatric facilities
licensed as hospitals.

G. The capital cost per day of freestanding psychiatric facilities
licensed as hospitals shall be the average charges per day of psychiatric cases
times the ratio total capital cost to total charges of the hospital, using data
available from Medicare cost report.

A. The freestanding psychiatric hospital specific rate per
day for psychiatric cases shall be equal to the hospital specific operating
rate per day, as determined in subsection A of 12VAC30-70-321 plus the hospital
specific capital rate per day for freestanding psychiatric cases.

B. The freestanding psychiatric hospital specific capital
rate per day for psychiatric cases shall be equal to the Medicare geographic
adjustment factor (GAF) for the hospital's geographic area times the statewide
capital rate per day for freestanding psychiatric cases times the percentage of
allowable cost specified in 12VAC30-70-271.

C. The statewide capital rate per day for psychiatric
cases shall be equal to the weighted average of the GAF-standardized capital
cost per day of facilities licensed as freestanding psychiatric hospitals.

D. The capital cost per day of facilities licensed as
freestanding psychiatric hospitals shall be the average charges per day of
psychiatric cases times the ratio total of capital cost to total charges of the
hospital, using data available from Medicare cost report.

E. Effective July 1, 2014, services provided under
arrangement, as defined in subdivisions B 6 a and B 6 b of 12VAC30-50-130,
shall be reimbursed directly by DMAS, according to the reimbursement
methodology prescribed for each provider in 12VAC30-80 or elsewhere in the
State Plan, to a provider of services under arrangement if all of the following
are met:

1. The services are included in the active treatment plan
of care developed and signed as described in subdivision C 4 of 12VAC30-60-25;
and

2. The services are arranged and overseen by the
freestanding psychiatric hospital treatment team through a written referral to
a Medicaid enrolled provider that is either an employee of the freestanding
psychiatric hospital or under contract for services provided under arrangement.

A. Effective January 1, 2000, DMAS shall pay for inpatient
psychiatric services in residential treatment facilities provided by
participating providers under the terms and payment methodology described in
this section.

B. Effective January 1, 2000, payment shall be made for
inpatient psychiatric services in residential treatment facilities using a per
diem payment rate as determined by DMAS based on information submitted by
enrolled residential psychiatric treatment facilities. This rate shall
constitute direct payment for all residential psychiatric treatment facility
services, excluding all services provided under arrangement that are reimbursed
in the manner described in subsection D of this section.

C. Enrolled residential treatment facilities shall submit
cost reports on uniform reporting forms provided by DMAS at such time as
required by DMAS. Such cost reports shall cover a 12-month period. If a
complete cost report is not submitted by a provider, DMAS shall take action in
accordance with its policies to assure that an overpayment is not being made.

D. Effective July 1, 2014, services provided under
arrangement, as defined in subdivisions B 6 a and B 6 b of 12VAC30-50-130,
shall be reimbursed directly by DMAS to a provider of services provided under
arrangement according to the reimbursement methodology prescribed for that
provider type elsewhere in the State Plan if all of the following are met:

1. The services provided under arrangement are included in
the active written treatment plan of care developed and signed as described in
section 12VAC30-130-890; and

2. The services provided under arrangement are arranged and
overseen by the residential treatment facility treatment team through a written
referral to a Medicaid enrolled provider that is either an employee of the
residential treatment facility or under contract for services provided under
arrangement.

NOTICE: The following
forms used in administering the regulation were filed by the agency. The forms
are not being published; however, online users of this issue of the Virginia
Register of Regulations may click on the name of a form with a hyperlink to
access it. The forms are also available from the agency contact or may be
viewed at the Office of the Registrar of Regulations, General Assembly
Building, 2nd Floor, Richmond, Virginia 23219.

FORMS (12VAC30-70)

Computation of Inpatient Operating Cost, HCFA-2552-92
D-1 (12/92).

Apportionment of Cost of Services Rendered by Interns and
Residents, HCFA-2552-92 D-2 (12/92).

Cost Reporting Forms for Hospitals (Map 783 Series), eff.
10/15/93

Certification by Officer or Administrator of Provider

Analysis of Interim Payments for Title XIX Services

Computation of Title XIX Ratio of Cost to Charges

Computation of Inpatient and Outpatient Ancillary Service
Costs

Computation of Outpatient Capital Reduction

Computation of Title XIX Outpatient Costs

Computation of Charges for Lower of Cost or Charge Comparison

Computation of Title XIX Reimbursement Settlement

Computation of Net Medicaid Inpatient Operating Cost
Adjustment

Calculation of Medicaid Inpatient Profit Incentive for
Hospitals

Plant Costs

Education Costs

Obstetrical Care Requirements Certification

Computation for Separating the Allowable Plant and Education
Cost (pass-throughs) from the Inpatient Medicaid Hospital Costs

A. Effective January 1, 2000, the state agency shall pay
for inpatient psychiatric services in residential treatment facilities provided
by participating providers, under the terms and payment methodology described
in this section.

B. Methodology. Effective January 1, 2000, payment will be
made for inpatient psychiatric services in residential treatment facilities
using a per diem payment rate as determined by the state agency based on
information submitted by enrolled residential psychiatric treatment facilities.
This rate shall constitute payment for all residential psychiatric treatment
facility services, excluding all professional services.

C. Data collection. Enrolled residential treatment
facilities shall submit cost reports on uniform reporting forms provided by the
state agency at such time as required by the agency. Such cost reports shall
cover a 12-month period. If a complete cost report is not submitted by a
provider, the Program shall take action in accordance with its policies to
assure that an overpayment is not being made.

A. Reimbursement for all services furnished to individuals
younger than 21 years of age who are residing in a freestanding psychiatric
hospital shall be based on the freestanding psychiatric hospital reimbursement
described in 12VAC30-70-415 and the reimbursement of services provided under
arrangement described in 12VAC30-80.

B. Reimbursement for all services furnished to individuals
younger than 21 years of age who are residing in a residential treatment center
(Level C) shall be based on the [ the ] residential
treatment center (Level C) reimbursement described in 12VAC30-70-417 and the
reimbursement of services provided under arrangement described in 12VAC30-80.

Part XIV
Residential Psychiatric Treatment for Children and Adolescents

12VAC30-130-850. Definitions.

The following words and terms when used in this part shall
have the following meanings, unless the context clearly indicates otherwise:

"Active treatment" means implementation of a
professionally developed and supervised individual plan of care that must be
designed to achieve the recipient's discharge from inpatient status at the
earliest possible time.

"Certification" means a statement signed by a
physician that inpatient services in a residential treatment facility are or
were needed. The certification must be made at the time of admission, or, if an
individual applies for assistance while in a mental hospital or residential
treatment facility, before the Medicaid agency authorizes payment.

"Comprehensive individual plan of care" or
"CIPOC" means a written plan developed for each recipient in
accordance with 12VAC30-130-890 to improve his condition to the extent that
inpatient care is no longer necessary.

"Emergency services" means a medical condition
manifesting itself by acute symptoms of sufficient severity (including severe
pain) such that a prudent layperson, who possesses an average knowledge of
health and medicine, could reasonably expect the absence of immediate medical
attention to result in placing the health of the individual (or, with respect
to a pregnant woman, the health of the woman or her unborn child) in serious
jeopardy, serious impairment to bodily functions, or serious dysfunction of any
bodily organ or part.

"Individual" or "individuals" means a
child or adolescent younger than 21 years of age who is receiving a service
covered under this part of this chapter.

"Initial plan of care" means a plan of care
established at admission, signed by the attending physician or staff physician,
that meets the requirements in 12VAC30-130-890.

"Recertification" means a certification for each
applicant or recipient that inpatient services in a residential treatment
facility are needed. Recertification must be made at least every 60 days by a
physician, or physician assistant or nurse practitioner acting within the scope
of practice as defined by state law and under the supervision of a physician.

"Recipient" or "recipients" means the
child or adolescent younger than 21 years of age receiving this covered
service.

"Services provided under arrangement" means
services including physician and other health care services that are furnished
to children while they are in an IPF that are billed by the arranged
practitioners separately from the IPF per diem.

12VAC30-130-890. Plans of care; review of plans of care.

A. All Medicaid services are subject to utilization review
and audit. The absence of any required documentation may result in denial or
retraction of any reimbursement.

B. For Residential Treatment Services (Level C) (RTS-Level
C), an initial plan of care must be completed at admission and a
Comprehensive Individual Plan of Care (CIPOC) must be completed no later than
14 days after admission.

4. Any orders for medications, treatments, restorative and
rehabilitative services, activities, therapies, social services, diet, and
special procedures recommended for the health and safety of the patientindividual
and a list of services provided under arrangement (see 12VAC30-50-130 for
eligible services provided under arrangement) that will be furnished to the
individual through the RTC-Level C's referral to an employed or a contracted
provider of services under arrangement, including the prescribed frequency of
treatment and the circumstances under which such treatment shall be sought;

5. Plans for continuing care, including review and
modification to the plan of care;

6. Plans for discharge; and

7. Signature and date by the physician.

C.D. The CIPOC for Level C must meet all of
the following criteria:

1. Be based on a diagnostic evaluation that includes
examination of the medical, psychological, social, behavioral, and
developmental aspects of the recipient'sindividual's situation
and must reflect the need for inpatient psychiatric care;

2. Be developed by an interdisciplinary team of physicians and
other personnel specified under subsection FG of this section,
who are employed by, or provide services to, patients in the facility in
consultation with the recipientindividual and his parents, legal
guardians, or appropriate others in whose care he will be released after
discharge;

3. State treatment objectives that must include measurable
short-term and long-term goals and objectives, with target dates for
achievement;

4. Prescribe an integrated program of therapies, activities,
and experiences designed to meet the treatment objectives related to the
diagnosis; and

5. Include a list of services provided under arrangement
(described in 12VAC30-50-130) that will be furnished to the individual through
referral to an employee or a contracted provider of services under arrangement,
including the prescribed frequency of treatment and the circumstances under
which such treatment shall be sought; and

6. Describe comprehensive discharge plans and
coordination of inpatient services and post-discharge plans with related
community services to ensure continuity of care upon discharge with the recipient'sindividual's family, school, and community.

D.E. Review of the CIPOC for Level C. The
CIPOC must be reviewed every 30 days by the team specified in subsection FG of this section to:

1. Determine that services being provided are or were required
on an inpatient basis; and

2. Recommend changes in the plan as indicated by the recipient'sindividual's overall adjustment as an inpatient.

E.F. The development and review of the plan of
care for Level C as specified in this section satisfies the facility's
utilization control requirements for recertification and establishment and
periodic review of the plan of care, as required in 42 CFR 456.160 and 456.180.

F.G. Team developing the CIPOC for Level C.
The following requirements must be met:

1. At least one member of the team must have expertise in
pediatric mental health. Based on education and experience, preferably
including competence in child psychiatry, the team must be capable of all of
the following:

b. A clinical psychologist who has a doctoral degree and a
physician licensed to practice medicine or osteopathy; or

c. A physician licensed to practice medicine or osteopathy
with specialized training and experience in the diagnosis and treatment of
mental diseases, and a psychologist who has a master's degree in clinical
psychology or who has been certified by the state or by the state psychological
association.

3. The team must also include one of the following:

a. A psychiatric social worker;

b. A registered nurse with specialized training or one year's
experience in treating mentally ill individuals;

c. An occupational therapist who is licensed, if required by
the state, and who has specialized training or one year of experience in
treating mentally ill individuals; or

d. A psychologist who has a master's degree in clinical
psychology or who has been certified by the state or by the state psychological
association.

G. All Medicaid services are subject to utilization
review. Absence of any of the required documentation may result in denial or
retraction of any reimbursement.H. The RTC-Level C shall not receive a
per diem reimbursement for any day that:

1. The initial or comprehensive written plan of care fails
to include within three business days of the initiation of the service provided
under arrangement:

[ (a) a. ] The prescribed
frequency of treatment of such service, or includes a frequency that was
exceeded; or

[ (b) b. ] All services that
the individual needs while residing at the RTC-Level C and that will be
furnished to the individual through the RTC-Level C referral to an employed or
contracted provider of services under arrangement [ .; ]

2. The initial or comprehensive written plan of care fails
to list the circumstances under which the service provided under arrangement
shall be sought;

3. The referral to the service provided under arrangement
was not present in the individual's RTC-Level C record;

4. The service provided under arrangement was not supported
in that provider's records by a documented referral from the RTC-Level C;

5. The medical records from the provider of services under
arrangement (i.e., admission and discharge documents, treatment plans, progress
notes, treatment summaries, and documentation of medical results and findings)
(i) were not present in the individual's RTC-Level C record or had not been
requested in writing by the RTC-Level C within seven days of discharge from or
completion of the service or services provided under arrangement or (ii) had
been requested in writing within seven days of discharge from or completion of
the service or services provided under arrangement, but not received within 30
days of the request, and not re-requested; or

6. The RTC-Level C did not have a fully executed contract
or employee relationship with an independent provider of services under
arrangement in advance of the provision of such services. For emergency
services, the RTC-Level C shall have a fully executed contract with the
emergency services provider prior to submission of the emergency service
provider's claim for payment.

7. A physician's order for the service under arrangement is
not present in the record.

8. The service under arrangement is not included in the
individual's CIPOC within 30 calendar days of the physician's order.

I. The provider of services under arrangement shall be
required to reimburse DMAS for the cost of any such service provided under
arrangement that was (i) furnished prior to receiving a referral or (ii) in
excess of the amounts in the referral. Providers of services under arrangement
shall be required to reimburse DMAS for the cost of any such services provided
under arrangement that were rendered in the absence of an employment or
contractual relationship.

H.J. For Therapeutic Behavioral Servicestherapeutic behavioral services for Childrenchildren and Adolescentsadolescents under 21 (Level B), the initial plan of care must be
completed at admission by the licensed mental health professional (LMHP) and a
CIPOC must be completed by the LMHP no later than 30 days after admission. The
assessment must be signed and dated by the LMHP.

I.K. For Community-Based Servicescommunity-based
services for Childrenchildren and Adolescentsadolescents
under 21 (Level A), the initial plan of care must be completed at admission by
the QMHP and a CIPOC must be completed by the QMHP no later than 30 days after
admission. The individualized plan of care must be signed and dated by the
program director.

4. Any orders for medications, treatments, restorative and
rehabilitative services, activities, therapies, social services, diet, and special
procedures recommended for the health and safety of the patient;

5. Plans for continuing care, including review and
modification to the plan of care; and

6. Plans for discharge.

K.M. The CIPOC for Levels A and B must meet
all of the following criteria:

1. Be based on a diagnostic evaluation that includes
examination of the medical, psychological, social, behavioral, and
developmental aspects of the child'sindividual's situation and
must reflect the need for residential psychiatric care;

2. The CIPOC for both levels must be based on input from
school, home, other healthcarehealth care providers, the childindividual and family (or legal guardian);

3. State treatment objectives that include measurable
short-term and long-term goals and objectives, with target dates for
achievement;

4. Prescribe an integrated program of therapies, activities,
and experiences designed to meet the treatment objectives related to the
diagnosis; and

5. Describe comprehensive discharge plans with related
community services to ensure continuity of care upon discharge with the child'sindividual's family, school, and community.

L.N. Review of the CIPOC for Levels A and B.
The CIPOC must be reviewed, signed, and dated every 30 days by the QMHP for
Level A and by the LMHP for Level B. The review must include:

1. The response to services provided;

2. Recommended changes in the plan as indicated by the child'sindividual's overall response to the plan of care interventions; and

3. Determinations regarding whether the services being
provided continue to be required.

Updates must be signed and dated by the service provider.

M. All Medicaid services are subject to utilization
review. Absence of any of the required documentation may result in denial or
retraction of any reimbursement.